Durable Medical Equipment and Orthotic and Prosthetic Manually Priced Procedure Codes - Prior Authorization Update

By April 1, 2023, DME and O&P providers must implement the following workflow changes: (1) When a beneficiary transitions from NC Medicaid Managed Care to NC Medicaid Direct, STOP relying on transferred PAs for manually priced DME and O&P procedure codes. (2) SUBMIT a new PA request to NCTracks for all manually priced DME and O&P codes listed on the NC Medicaid Fee Schedule, regardless of previous Managed Care PA status. (3) For retroactive claims (disenrollment on or after April 1, 2023), SUBMIT retroactive PA requests within 90 days of the health plan's recoupment notice letter, using the later of: the NC Medicaid Direct coverage begin date OR the coverage issue date as the effective date. (4) DOCUMENT all retroactive PA requests with a copy of the original health plan PA if one was issued. (5) VERIFY beneficiary eligibility and enrollment status in NCTracks BEFORE submitting any PA or providing services. If retroactive PA submission is not possible within 90 days or other barriers exist, CONTACT the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov with the required ticket information (subject line, provider name, NPI, previous health plan, MID, procedure codes, dates of service). Failure to submit new PAs will result in claims being rejected or recouped by NC Medicaid Direct.